Chronic pelvic pain

Template:Search infobox Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Most women (and some men), at some time in their lives, experience pelvic pain. When the condition persists for longer than 3 months, it is called chronic pelvic pain (CPP). This is a poorly-understood condition that likely represents abnormal neurological function, either in the peripheral nervous system or central nervous system. Many different etiologies have been proposed for CPP, but a major problem is that virtually none of them have been validated.

Women with symptoms of pain may want to see a gynecologist if problems don't go away after a few days, and workup should begin with a careful history and examination, followed by a pregnancy test. Some women may also need bloodwork or additional imaging studies, and a handful may also benefit from having surgical evaluation using small telescopes (laparoscopy). Many women will also benefit from a consultation with a physical therapist, a trial of anti-inflammatory medications, hormonal therapy, or even neurological agents.

This is a condition that although common, direly needs to be studied more closely.

Historical Perspective

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Pathophysiology

The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3]. The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway. On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name]. On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Chronic Pelvic Pain in Female Adolescents

As girls enter gynecologic maturity, pelvic or abdominal pain becomes a frequent complaint.

Chronic pelvic pain (CPP) accounts for 10% of all visits to gynecologists. In addition, CPP is the reason for 20 - 30% of all laparoscopies in adults.

Causes

Common Causes

Commonly proposed etiologies include:

• Endometriosis (very controversial) Deeply Infiltrative Endometriosis may be more important
• Infection or post-infectious neurological hypersensitivity
• Exaggerated bladder, bowel, or uterine pain sensitivity (also known as visceral pain)
• Ovarian cysts, uterine leiomyoma - often found in asymptomatic patients as well, however
• Less common emergencies: ovarian torsion - sudden loss of circulation to the ovary, appendicitis - infection of one part of the intestine, with right lower abdominal pain, ectopic pregnancy - where an early pregnancy grows outside of the uterus, and can cause sudden, heavy intra-abdominal bleeding
• Pelvic girdle pain (SPD or DSP)

Causes by Organ System

Cardiovascular	Pelvic vein thrombosis
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	Anal fissure, Appendicitis, Colitis, Colonic polyps, Constipation, Diarrhea, Diverticulitis, Gastrointestinal cancers, Hemorrhoids, Internal hernia, Irritable bowel syndrome, Proctitis, Reproductive tract cancers, Strangulated hernia, Ulcerative colitis
Genetic	No underlying causes
Hematologic	Porphyria
Iatrogenic	Ovarian remnant
Infectious Disease	UTI
Musculoskeletal / Ortho	Coccydynia, Low back pain, Muscle spasm, Pelvic girdle malrotation, Tension in the pelvic floor muscles
Neurologic	Nerve entrapment in pelvis, Peripheral neuropathy in pelvis, Post herpetic neuralgia, Post infectious neurological hypersensitivity, Pudendal nerve neuralgia
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	Adenomyosis, Adhesions in the pelvic area, Cervical polyps, Chronic vulvovaginitis, Dysmenorrhea, Ectopic pregnancy, Endometrial polyps, Endometriosis, Fibroids, Miscarriage, Mittelschmerz pain, Mullerian abnormalities, Ovarian cysts, Ovarian torsion, Pelvic congestion syndrome, Pelvic inflammatory disease, Pelvic relaxation, Placental abruption, Retroverted uterus, Uterine leiomyoma, Vulvodynia
Oncologic	Colon cancer, Neuromas, Pelvic tumor, Testicular tumors
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	Chronic stress, Depression
Pulmonary	No underlying causes
Renal / Electrolyte	Loin pain hematuria syndrome
Rheum / Immune / Allergy	Fibromyalgia
Sexual	Clitorodynia, Epididymo-orchitis, Sexual abuse
Trauma	Physical abuse
Urologic	Chronic bacterial prostatitis, Chronic bladder irritation, Chronic non bacterial prostatitis, Chronic pelvic pain syndrome, Chronic urethritis, Epididymal cysts, Hydrocele, Interstitial cystitis, Urinary tract calculi, Varicocele
Dental	No underlying causes
Miscellaneous	No underlying causes

Causes in Alphabetical Order

Adenomyosis Adhesions in the pelvic area Anal fissure Appendicitis Cervical polyps Chronic bacterial prostatitis Chronic bladder irritation Chronic non bacterial prostatitis Chronic pelvic pain syndrome Chronic stress Chronic urethritis Chronic vulvovaginitis Clitorodynia Coccydynia Colitis Colon cancer Colonic polyps Constipation Depression Diarrhea Diverticulitis Dysmenorrhea Ectopic pregnancy Endometrial polyps Endometriosis Epididymal cysts Epididymo-orchitis Fibroids Fibromyalgia Gastrointestinal cancers Hemorrhoids Hydrocele Internal hernia Interstitial cystitis Irritable bowel syndrome Loin pain hematuria syndrome

Low back pain Miscarriage Mittelschmerz pain Mullerian abnormalities Muscle spasm Nerve entrapment in pelvis Neuromas Ovarian cysts Ovarian remnant Ovarian torsion Pelvic congestion syndrome Pelvic girdle malrotation Pelvic inflammatory disease Pelvic relaxation Pelvic tumor Pelvic vein thrombosis Peripheral neuropathy in pelvis Physical abuse Placental abruption Porphyria Post herpetic neuralgia Post infectious neurological hypersensitivity Proctitis Pudendal nerve neuralgia Reproductive tract cancers Retroverted uterus Sexual abuse Strangulated hernia Tension in the pelvic floor muscles Testicular tumors Ulcerative colitis Urinary tract calculi Uterine leiomyoma UTI Varicocele Vulvodynia

Additional Resources

• Milburn A, Reiter R, Rhomberg A: Multi-disciplinary approach to chronic pain. Obstet Gynecol Clin 1993;20:643 - 661.
• Stovall DW: Endometriosis associated pelvic pain: Evidence for an association between the stage of disease and a history of chronic pelvic pain. Fertil Steril 1997;68:13 - 17.
• Schroeder B, Sanfillippo JS: Chronic Pelvic Pain and Recurrent Abdominal Pain in Female Adolescents. Pediatr Clin North Am 1999;46:566 - 567.
• Elisabeth Thibaud, Hyams JS: Clinical aspects of recurrent abdominal pain. Pediatric and Adolescent GynecologyPediatr Ann 2001;30:17–21.
• Jantos M.: Understanding Chronic Pelvic Pain. Pelviperineology Vol. 26 N.2 June 2007 66-68

Related Chapters

• Abdominal adhesions
• Coccydynia (coccyx pain, tailbone pain)

External Links

• International Pelvic Pain Society
• Pelvic Floor Digest: Free Selected medical abstracts on pelvic pain. Updated
• American Pain Society
• Endometriosis Research Center
• endometriosis.org
• Endometriosis Association
• Pelviperineology The multidisciplinary open access pelvic floor journal

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